Journal of Pediatric Surgery 49 (2014) 590–592
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Early tracheostomy improves outcomes in severely injured children and adolescents☆ Courtenay M. Holscher a,⁎, Camille L. Stewart a, Erik D. Peltz b, Clay Cothren Burlew a, b, Steven L. Moulton a, c, James B. Haenel b, Denis D. Bensard a, b a b c
University of Colorado School of Medicine, Aurora, CO, USA Denver Health Medical Center, Denver, CO, USA Children's Hospital Colorado, Aurora, CO, USA
a r t i c l e
i n f o
Article history: Received 13 June 2013 Received in revised form 3 August 2013 Accepted 1 September 2013 Key words: Trauma Pediatrics Tracheostomy
a b s t r a c t Background: Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. Methods: Injured children undergoing tracheostomy over a 10-year period (2002–2012) were reviewed. Early tracheostomy was defined as post-injury day ≤7. Data were compared using Student's t test, Pearson chisquared test and Fisher exact test. Statistical significance was set at p b 0.05 with 95% confidence intervals. Results: During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were b 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p = 0.003), ICU days (p = 0.003), hospital days (p = 0.046), and tracheal complications (p = 0.03) compared to late tracheostomy. There was no difference in pneumonia (p = 0.48) between early and late tracheostomy. Conclusion: Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. Summary: Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7. © 2014 Elsevier Inc. All rights reserved.
Early tracheostomy is often utilized in severely injured adults. Early tracheostomy appears to improve resource utilization [1–3], particularly with the increasing use of the bedside percutaneous technique [2,4], and is associated with decreased duration of mechanical ventilation, length of ICU stay, length of hospital stay, and incidence of ventilator associated pneumonia [1,3,5–17]. It is further advocated to improve patient comfort and decrease sedation requirements [18]. Trauma is the leading cause of mortality in children, yet timing of tracheostomy in severely injured children has not been extensively studied. Tracheostomy in injured children has been shown to be safe with fewer complications than prolonged intubation [19]. Percutaneous tracheostomy in injured children has also been shown to be safe [20], suggesting the same improved resource utilization using percutaneous bedside tracheostomy seen in adults may be seen in ☆ None of the authors have any conflict of interest to report. ⁎ Corresponding author. Tel.: +1 513 608 4646; fax: +1 303 436 6572. E-mail addresses: [email protected] (C.M. Holscher), [email protected] (D.D. Bensard). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.09.002
children. We hypothesized that early tracheostomy in injured children would reduce duration of mechanical ventilation, length of ICU stay, length of hospital stay, and ventilator associated pneumonia as observed in adults. 1. Methods Trauma registries from two academic level I trauma centers were queried for patients aged b 18 years undergoing tracheostomy after traumatic injury over a 10-year period, from January 2002 to January 2012. The study centers were Children's Hospital Colorado, a regional pediatric level I trauma center located in Aurora, Colorado, and Denver Health Medical Center, the rocky mountain regional level I trauma center located in Denver, Colorado. Both centers' faculty includes pediatric trauma surgeons, pediatric emergency medicine physicians, and pediatric intensivists, and both serve as regional referral centers for pediatric trauma. At Denver Health Medical Center, pediatric and adult trauma surgeons comprise the surgical intensive care unit faculty, and as such pediatric management decisions at this trauma center were also influenced by adult trauma surgeons.
C.M. Holscher et al. / Journal of Pediatric Surgery 49 (2014) 590–592
Demographic data, interventions, outcomes, and complications were identified from pre-hospital reports, the trauma registry, and hospital charts. Early tracheostomy was defined as tracheostomy on post-injury day 7 or earlier. Patients undergoing emergent cricothyroidotomy, emergent tracheostomy, or conversion to tracheostomy following emergent cricothyroidotomy were excluded. If patients were discharged on mechanical ventilation, ventilator days were recorded as equal to hospital days. Data are presented as mean ± standard deviation or percentages. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p b 0.05 with 95% confidence intervals. All analyses were two-tailed. Statistical analysis was done with IBM SPSS Statistics for Windows (Version 20, Armonk, NY). The Colorado Multiple Institutional Review Board approved this retrospective study with a waiver of informed consent.
Nursing home 6% Other 9%
591
Mortality 2%
Home 16%
Rehabilitation 67%
2. Results Fig. 1. Patient disposition.
During the 10-year study period, 91 patients underwent tracheostomy following traumatic injury. The mean age was 13 years ± 5 years (range 1 month to 18 years), 74% were male, and the mean injury severity score (ISS) was 35 ± 15. Twenty-nine (32%) children undergoing tracheostomy were age 12 years or younger, while 62 (68%) were adolescents aged 13 to 18 years old. Children aged 12 years or younger were more likely to have presented to Children's Hospital Colorado (27/29, 93%) while adolescents aged 13–18 years were more likely to have presented to Denver Health Medical Center (55/62, 89%, p b 0.01). The most common mechanisms of injury were motor vehicle collisions (41%), pedestrians struck (15%) and gunshot wounds (9%), followed by falls, motorcycle accidents, off-road vehicle accidents, bicycle accidents, assaults, burns, and other injuries. The majority (68/91, 75%) of patients had a severe traumatic brain injury (presenting Glasgow Coma Scale b 8) or a complete cervical spinal cord injury with a mean ISS of 37 ± 14 for this group. Patients with a severe traumatic brain injury or complete cervical spinal cord injury were more likely to undergo late tracheostomy (p = 0.048); otherwise there were no differences in age, gender, or ISS between patients undergoing early versus late tracheostomy (Table 1). The majority of all patients (61/91, 67%) were discharged to rehabilitation and 2/91 (2%) died (Fig. 1). The mean timing for tracheostomy in all patients was post-injury day 10 ± 8 (range 0–38 days). Percutaneous technique was employed in 54/91 (59%) of patients; nearly all (52/54, 96%) patients who underwent percutaneous tracheostomy were in the adolescent age group. Overall, 43/91 (47%) underwent early tracheostomy, on or before post-injury day 7. In the subgroup of patients aged 12 years or younger, 11/29 (38%) underwent early tracheostomy, while in the subgroup of adolescents aged 13 to 18 years, 32/62 (52%) underwent early tracheostomy. There was benefit in the early tracheostomy group as compared to late tracheostomy in ventilator days (14 days versus 21 days, p = 0.003), ICU days (19 days versus 27 days, p = 0.003), hospital days (26 days versus 37 days, p = 0.046), and
prevalence of tracheal complications (5% versus 21%, p = 0.03). There was no difference in prevalence of pneumonia (58% versus 65%, p = 0.5) between those undergoing early versus late tracheostomy (Table 2). In subgroup analysis of patients aged 12 years or younger, continued significance was seen in fewer ventilator days, ICU days, and hospital days for those undergoing early tracheostomy. In subgroup analysis of patients aged 13 to 18 years, these trends were not significant (Table 2). Thirteen airway complications were seen in 12 patients; these were tracheitis (n = 6), subglottic stenosis (n = 2), endotracheal granuloma (n = 1), glottis granuloma (n = 1), tracheomalacia (n = 1), arytenoid dislocation (n = 1), and vocal cord hypofunction (n = 1). There was no difference in prevalence of tracheitis between those undergoing early versus late tracheostomy (5% versus 8%, p = 0.7). Excluding tracheitis, all airway complications were seen in patients who received late tracheostomy (p = 0.03). 3. Discussion To our knowledge, this is the first study examining the timing of tracheostomy for pediatric trauma patients. Studies in adults have reported that early tracheostomy is associated with reduced ventilator days [1,5,6,9,11,12,15], reduced length of ICU stay [1,3,11,12,15], and reduced length of hospital stay [3,6,8,11,15]. There are however, other conflicting reports suggesting that timing has no effect on ventilator [10,14,17], ICU days [10,13,14], or hospital days [17]. In our study, we found reduced ventilator days, length of ICU stay, and length of hospital stay with early tracheostomy. The majority of our cohort presented with a severe head injury or cervical spinal cord injury, and the majority required prolonged mechanical ventilation. Early tracheostomy is recommended in adult patients with severe head injuries and in adults who are anticipated to require mechanical
Table 1 Patient demographics and injuries by age and tracheostomy timing. Age ≤12 (n = 29)
All (n = 91)
Demographic Age Male gender Injury Complete cervical spinal cord injury and/or severe traumatic brain injury Injury Severity Score
Early (n = 43)
Late (n = 48)
14 (13–16) 29 (67%)
13 (11–14) 38 (79%)
28 (65%)⁎ 34 (29–39)
Early (n = 11)
Age 13–18 (n = 62) Late (n = 18)
Early (n = 32)
Late (n = 30)
8 (6–10) 7 (64%)
6 (4–8) 14 (78%)
17 (16–17) 22 (69%)
16 (16–17) 24 (80%)
40 (83%)⁎
8 (73%)
16 (89%)
20 (63%)
24 (80%)
36 (32–40)
23 (16–32)
33 (28–39)
38 (32–43)
38 (33–43)
⁎ Difference statistically significant at p b 0.05 Data presented as mean (95% confidence interval) or number (percentage).
592
C.M. Holscher et al. / Journal of Pediatric Surgery 49 (2014) 590–592
Table 2 Treatment and complications by age and tracheostomy timing. Age ≤12 (n = 29)
All (n = 91)
Post-injury days at tracheostomy Percutaneous tracheostomy Ventilator days ICU days Hospital days Pneumonia Airway complication
Early (n = 43)
Late (n = 48)
4 (3–4)⁎ 29 (67%) 14 (11–17)⁎ 19 (16–22)⁎ 26 (22–30)⁎ 25 (58%) 2 (5%)⁎
15 25 21 27 37 31 10
(13–17)⁎ (52%) (18–24)⁎ (23–32)⁎ (29–50)⁎ (65%) (21%)⁎
Age 13–18 (n = 62)
Early (n = 11)
Late (n = 18)
3 (1–5)⁎ 1 (9%) 9 (5–14)⁎ 13 (8–20)⁎ 18 (13–23)⁎ 2 (18%) 0
20 1 23 25 31 9 5
(15–24)⁎ (6%) (17–28)⁎ (21–30)⁎ (26–36)⁎ (50%) (28%)
Early (n = 32) 4 28 15 19 30 23 2
(3–5)⁎ (88%) (10–20) (13–26) (22–40) (72%) (6%)
Late (n = 30) 13 (11–15)⁎ 24 (80%) 19 (16–23) 27 (21–35) 40 (28–56) 22 (73%) 5 (17%)
⁎ Difference within age group statistically significant at p b 0.05 Data presented as mean (95% confidence interval) or number (percentage).
ventilation for more than 7 days [21]. Our results suggest that the recommendations for adults are also applicable to pediatric trauma patients, especially the younger pediatric population. We found that our cohort of severely injured patients undergoing tracheostomy had a high prevalence of pneumonia (62%) and a lower prevalence of tracheitis (7%). Previous reports demonstrating that ventilator-associated pneumonia is significantly associated with tracheostomy in trauma patients in the pediatric intensive care unit [22] and that tracheitis is not associated with tracheostomy [23] corroborate our findings. We found no significant difference in pneumonia or tracheitis between those undergoing early versus late tracheostomy. We did, however, observe a trend toward less pneumonia in patients receiving early tracheostomy versus late tracheostomy, consistent with the experience of others showing similar [7,10,12–14] or lower [5,11,15] pneumonia rates with early tracheostomy in adults. It has been suggested that most tracheal complications seen after tracheostomy in children result from intubation following trauma [19]. Likewise, trends have been reported toward more vocal cord ulceration and subglottic inflammation in patients undergoing prolonged intubation compared to early tracheostomy [13]. A low proportion of our cohort (12/91, 13%) had airway complications and these were more frequently seen in patients undergoing late tracheostomy. Other studies have reported higher airway complication rates following tracheostomy; however, patients in these studies were much younger than patients in our cohort [24,25]. The limitations of this study are inherent to its retrospective design. This precluded analysis of subjective measures often cited as advantages of tracheostomy, such as patient comfort, sedation requirements, ease of nursing care, or ease of ambulation. We included only patients undergoing tracheostomy, thus prohibiting comparison to patients undergoing prolonged intubation. This likely excluded those patients with less severe injuries who ultimately did require prolonged intubation, as well as excluded those patients with injuries so severe they were thought unsalvageable. Additionally it is a possibility that those patients with injuries so severe they may have initially been considered unsalvageable and not candidates for early tracheostomy did later undergo tracheostomy; however, we did not see a difference in ISS between patients undergoing early versus late tracheostomy in our cohort. Further studies in severely injured children are needed to compare early tracheostomy to prolonged translaryngeal intubation.
Acknowledgments This was presented at the Southwestern Surgical Congress 2013 Annual Meeting, in Santa Barbara, CA, March 24–27, 2013.
References [1] Arabi Y, Haddad S, Shirawi N, Shimemeri AA. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care 2004;8(5):R347–52. [2] Mirski M, Pandian V, Bhatti N, et al. Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Crit Care Med 2012;40(6):1827–34. [3] Armstrong P, McCarthy M, Peoples J. Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma. Surgery 1998;124(4):763–6. [4] Kornblith L, Burlew C, Moore E, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg 2011;212(2):163–70. [5] Lesnik I, Rappaport W, Fulginiti J, Witzke D. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg 1992;58(6):346–9. [6] Leelapattana P, Fleming J, Gurr K, et al. Predicting the need for tracheostomy in patients with cervical spinal cord injury. J Trauma Acute Care Surg 2012;73(4):880–4. [7] Romero J, Vari A, Gambarrutta C, Oliviero A. Tracheostomy timing in traumatic spinal cord injury. Eur Spine J 2009;18(10):1452–7. [8] Rizk E, Patel A, Stetter C, et al. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care 2011;15(3):481–9. [9] Bouderka M, Fakhir B, Bouaggad A, et al. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004;57(2):251–4. [10] Dunham C, Ransom K. Assessment of early tracheostomy in trauma patients: a systematic review and meta-analysis. Am Surg 2006;72(3):276–81. [11] Schauer J, Engle L, Maugher D, Cherry R. Does acuity matter? Optimal timing of tracheostomy stratified by injury severity. J Trauma 2009;66(1):220–5. [12] Griffiths J, Barber V, Morgan L, Young J. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330(7502):1243–7. [13] Sugerman H, Wolfe L, Pasquale M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 1997;43(5):741–7. [14] Barquist E, Amortegui J, Hallal A, et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma 2006;60(1):91–7. [15] Möller M, Slaikeu J, Bonelli P, et al. Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 2005;189(3):293–6. [16] Silva BG, Andriolo R, Saconato H, et al. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev 2012;3 CD007271. [17] Engoren M, Arslanian-Engoren C. Hospital and long-term outcome of trauma patients with tracheostomy for respiratory failure. Am Surg 2005;71(2):123–7. [18] Goettler C, Fugo J, Bard M, et al. Predicting the need for early tracheostomy: a multifactorial analysis of 992 intubated trauma patients. J Trauma 2006;60(5):991–6. [19] Rocha E, Dias M, Szajmbok F, et al. Tracheostomy in children: there is a place for acceptable risk. J Trauma 2000;49(3):483–5. [20] Raju A, Joseph D, Diarra C, Ross S. Percutaneous versus open tracheostomy in the pediatric trauma population. Am Surg 2010;76(3):276–8. [21] Holevar M, Dunham J, Brautigan R, et al. Practice management guidelines for timing of tracheostomy: the EAST Practice Management Guidelines Work Group. J Trauma 2009;67(4):870–4. [22] Bigham M, Amato R, Bondurrant P, et al. Ventilator-associated pneumonia in the pediatric intensive care unit: characterizing the problem and implementing a sustainable solution. J Pediatr 2009;154(4):582–7. [23] Mhanna M, Elsheikh I, Super D. Risk factors and outcome of ventilator associated trachei tis (VAT) i n pedi atri c trauma p atients. Pediatr Pu lmonol 2013;48(2):176–81. [24] Berry J, Graham D, Graham R, et al. Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics 2009;124(2):563–72. [25] Midwinter K, Carrie S, Bull P. Paediatric tracheostomy: Sheffield experience 1979– 1999. J Laryngol Otol 2002;116(7):532–5.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Early tracheostomy improves outcomes in severely injured children and adolescents☆ Courtenay M. Holscher a,⁎, Camille L. Stewart a, Erik D. Peltz b, Clay Cothren Burlew a, b, Steven L. Moulton a, c, James B. Haenel b, Denis D. Bensard a, b a b c
University of Colorado School of Medicine, Aurora, CO, USA Denver Health Medical Center, Denver, CO, USA Children's Hospital Colorado, Aurora, CO, USA
a r t i c l e
i n f o
Article history: Received 13 June 2013 Received in revised form 3 August 2013 Accepted 1 September 2013 Key words: Trauma Pediatrics Tracheostomy
a b s t r a c t Background: Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. Methods: Injured children undergoing tracheostomy over a 10-year period (2002–2012) were reviewed. Early tracheostomy was defined as post-injury day ≤7. Data were compared using Student's t test, Pearson chisquared test and Fisher exact test. Statistical significance was set at p b 0.05 with 95% confidence intervals. Results: During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were b 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p = 0.003), ICU days (p = 0.003), hospital days (p = 0.046), and tracheal complications (p = 0.03) compared to late tracheostomy. There was no difference in pneumonia (p = 0.48) between early and late tracheostomy. Conclusion: Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. Summary: Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7. © 2014 Elsevier Inc. All rights reserved.
Early tracheostomy is often utilized in severely injured adults. Early tracheostomy appears to improve resource utilization [1–3], particularly with the increasing use of the bedside percutaneous technique [2,4], and is associated with decreased duration of mechanical ventilation, length of ICU stay, length of hospital stay, and incidence of ventilator associated pneumonia [1,3,5–17]. It is further advocated to improve patient comfort and decrease sedation requirements [18]. Trauma is the leading cause of mortality in children, yet timing of tracheostomy in severely injured children has not been extensively studied. Tracheostomy in injured children has been shown to be safe with fewer complications than prolonged intubation [19]. Percutaneous tracheostomy in injured children has also been shown to be safe [20], suggesting the same improved resource utilization using percutaneous bedside tracheostomy seen in adults may be seen in ☆ None of the authors have any conflict of interest to report. ⁎ Corresponding author. Tel.: +1 513 608 4646; fax: +1 303 436 6572. E-mail addresses: [email protected] (C.M. Holscher), [email protected] (D.D. Bensard). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.09.002
children. We hypothesized that early tracheostomy in injured children would reduce duration of mechanical ventilation, length of ICU stay, length of hospital stay, and ventilator associated pneumonia as observed in adults. 1. Methods Trauma registries from two academic level I trauma centers were queried for patients aged b 18 years undergoing tracheostomy after traumatic injury over a 10-year period, from January 2002 to January 2012. The study centers were Children's Hospital Colorado, a regional pediatric level I trauma center located in Aurora, Colorado, and Denver Health Medical Center, the rocky mountain regional level I trauma center located in Denver, Colorado. Both centers' faculty includes pediatric trauma surgeons, pediatric emergency medicine physicians, and pediatric intensivists, and both serve as regional referral centers for pediatric trauma. At Denver Health Medical Center, pediatric and adult trauma surgeons comprise the surgical intensive care unit faculty, and as such pediatric management decisions at this trauma center were also influenced by adult trauma surgeons.
C.M. Holscher et al. / Journal of Pediatric Surgery 49 (2014) 590–592
Demographic data, interventions, outcomes, and complications were identified from pre-hospital reports, the trauma registry, and hospital charts. Early tracheostomy was defined as tracheostomy on post-injury day 7 or earlier. Patients undergoing emergent cricothyroidotomy, emergent tracheostomy, or conversion to tracheostomy following emergent cricothyroidotomy were excluded. If patients were discharged on mechanical ventilation, ventilator days were recorded as equal to hospital days. Data are presented as mean ± standard deviation or percentages. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p b 0.05 with 95% confidence intervals. All analyses were two-tailed. Statistical analysis was done with IBM SPSS Statistics for Windows (Version 20, Armonk, NY). The Colorado Multiple Institutional Review Board approved this retrospective study with a waiver of informed consent.
Nursing home 6% Other 9%
591
Mortality 2%
Home 16%
Rehabilitation 67%
2. Results Fig. 1. Patient disposition.
During the 10-year study period, 91 patients underwent tracheostomy following traumatic injury. The mean age was 13 years ± 5 years (range 1 month to 18 years), 74% were male, and the mean injury severity score (ISS) was 35 ± 15. Twenty-nine (32%) children undergoing tracheostomy were age 12 years or younger, while 62 (68%) were adolescents aged 13 to 18 years old. Children aged 12 years or younger were more likely to have presented to Children's Hospital Colorado (27/29, 93%) while adolescents aged 13–18 years were more likely to have presented to Denver Health Medical Center (55/62, 89%, p b 0.01). The most common mechanisms of injury were motor vehicle collisions (41%), pedestrians struck (15%) and gunshot wounds (9%), followed by falls, motorcycle accidents, off-road vehicle accidents, bicycle accidents, assaults, burns, and other injuries. The majority (68/91, 75%) of patients had a severe traumatic brain injury (presenting Glasgow Coma Scale b 8) or a complete cervical spinal cord injury with a mean ISS of 37 ± 14 for this group. Patients with a severe traumatic brain injury or complete cervical spinal cord injury were more likely to undergo late tracheostomy (p = 0.048); otherwise there were no differences in age, gender, or ISS between patients undergoing early versus late tracheostomy (Table 1). The majority of all patients (61/91, 67%) were discharged to rehabilitation and 2/91 (2%) died (Fig. 1). The mean timing for tracheostomy in all patients was post-injury day 10 ± 8 (range 0–38 days). Percutaneous technique was employed in 54/91 (59%) of patients; nearly all (52/54, 96%) patients who underwent percutaneous tracheostomy were in the adolescent age group. Overall, 43/91 (47%) underwent early tracheostomy, on or before post-injury day 7. In the subgroup of patients aged 12 years or younger, 11/29 (38%) underwent early tracheostomy, while in the subgroup of adolescents aged 13 to 18 years, 32/62 (52%) underwent early tracheostomy. There was benefit in the early tracheostomy group as compared to late tracheostomy in ventilator days (14 days versus 21 days, p = 0.003), ICU days (19 days versus 27 days, p = 0.003), hospital days (26 days versus 37 days, p = 0.046), and
prevalence of tracheal complications (5% versus 21%, p = 0.03). There was no difference in prevalence of pneumonia (58% versus 65%, p = 0.5) between those undergoing early versus late tracheostomy (Table 2). In subgroup analysis of patients aged 12 years or younger, continued significance was seen in fewer ventilator days, ICU days, and hospital days for those undergoing early tracheostomy. In subgroup analysis of patients aged 13 to 18 years, these trends were not significant (Table 2). Thirteen airway complications were seen in 12 patients; these were tracheitis (n = 6), subglottic stenosis (n = 2), endotracheal granuloma (n = 1), glottis granuloma (n = 1), tracheomalacia (n = 1), arytenoid dislocation (n = 1), and vocal cord hypofunction (n = 1). There was no difference in prevalence of tracheitis between those undergoing early versus late tracheostomy (5% versus 8%, p = 0.7). Excluding tracheitis, all airway complications were seen in patients who received late tracheostomy (p = 0.03). 3. Discussion To our knowledge, this is the first study examining the timing of tracheostomy for pediatric trauma patients. Studies in adults have reported that early tracheostomy is associated with reduced ventilator days [1,5,6,9,11,12,15], reduced length of ICU stay [1,3,11,12,15], and reduced length of hospital stay [3,6,8,11,15]. There are however, other conflicting reports suggesting that timing has no effect on ventilator [10,14,17], ICU days [10,13,14], or hospital days [17]. In our study, we found reduced ventilator days, length of ICU stay, and length of hospital stay with early tracheostomy. The majority of our cohort presented with a severe head injury or cervical spinal cord injury, and the majority required prolonged mechanical ventilation. Early tracheostomy is recommended in adult patients with severe head injuries and in adults who are anticipated to require mechanical
Table 1 Patient demographics and injuries by age and tracheostomy timing. Age ≤12 (n = 29)
All (n = 91)
Demographic Age Male gender Injury Complete cervical spinal cord injury and/or severe traumatic brain injury Injury Severity Score
Early (n = 43)
Late (n = 48)
14 (13–16) 29 (67%)
13 (11–14) 38 (79%)
28 (65%)⁎ 34 (29–39)
Early (n = 11)
Age 13–18 (n = 62) Late (n = 18)
Early (n = 32)
Late (n = 30)
8 (6–10) 7 (64%)
6 (4–8) 14 (78%)
17 (16–17) 22 (69%)
16 (16–17) 24 (80%)
40 (83%)⁎
8 (73%)
16 (89%)
20 (63%)
24 (80%)
36 (32–40)
23 (16–32)
33 (28–39)
38 (32–43)
38 (33–43)
⁎ Difference statistically significant at p b 0.05 Data presented as mean (95% confidence interval) or number (percentage).
592
C.M. Holscher et al. / Journal of Pediatric Surgery 49 (2014) 590–592
Table 2 Treatment and complications by age and tracheostomy timing. Age ≤12 (n = 29)
All (n = 91)
Post-injury days at tracheostomy Percutaneous tracheostomy Ventilator days ICU days Hospital days Pneumonia Airway complication
Early (n = 43)
Late (n = 48)
4 (3–4)⁎ 29 (67%) 14 (11–17)⁎ 19 (16–22)⁎ 26 (22–30)⁎ 25 (58%) 2 (5%)⁎
15 25 21 27 37 31 10
(13–17)⁎ (52%) (18–24)⁎ (23–32)⁎ (29–50)⁎ (65%) (21%)⁎
Age 13–18 (n = 62)
Early (n = 11)
Late (n = 18)
3 (1–5)⁎ 1 (9%) 9 (5–14)⁎ 13 (8–20)⁎ 18 (13–23)⁎ 2 (18%) 0
20 1 23 25 31 9 5
(15–24)⁎ (6%) (17–28)⁎ (21–30)⁎ (26–36)⁎ (50%) (28%)
Early (n = 32) 4 28 15 19 30 23 2
(3–5)⁎ (88%) (10–20) (13–26) (22–40) (72%) (6%)
Late (n = 30) 13 (11–15)⁎ 24 (80%) 19 (16–23) 27 (21–35) 40 (28–56) 22 (73%) 5 (17%)
⁎ Difference within age group statistically significant at p b 0.05 Data presented as mean (95% confidence interval) or number (percentage).
ventilation for more than 7 days [21]. Our results suggest that the recommendations for adults are also applicable to pediatric trauma patients, especially the younger pediatric population. We found that our cohort of severely injured patients undergoing tracheostomy had a high prevalence of pneumonia (62%) and a lower prevalence of tracheitis (7%). Previous reports demonstrating that ventilator-associated pneumonia is significantly associated with tracheostomy in trauma patients in the pediatric intensive care unit [22] and that tracheitis is not associated with tracheostomy [23] corroborate our findings. We found no significant difference in pneumonia or tracheitis between those undergoing early versus late tracheostomy. We did, however, observe a trend toward less pneumonia in patients receiving early tracheostomy versus late tracheostomy, consistent with the experience of others showing similar [7,10,12–14] or lower [5,11,15] pneumonia rates with early tracheostomy in adults. It has been suggested that most tracheal complications seen after tracheostomy in children result from intubation following trauma [19]. Likewise, trends have been reported toward more vocal cord ulceration and subglottic inflammation in patients undergoing prolonged intubation compared to early tracheostomy [13]. A low proportion of our cohort (12/91, 13%) had airway complications and these were more frequently seen in patients undergoing late tracheostomy. Other studies have reported higher airway complication rates following tracheostomy; however, patients in these studies were much younger than patients in our cohort [24,25]. The limitations of this study are inherent to its retrospective design. This precluded analysis of subjective measures often cited as advantages of tracheostomy, such as patient comfort, sedation requirements, ease of nursing care, or ease of ambulation. We included only patients undergoing tracheostomy, thus prohibiting comparison to patients undergoing prolonged intubation. This likely excluded those patients with less severe injuries who ultimately did require prolonged intubation, as well as excluded those patients with injuries so severe they were thought unsalvageable. Additionally it is a possibility that those patients with injuries so severe they may have initially been considered unsalvageable and not candidates for early tracheostomy did later undergo tracheostomy; however, we did not see a difference in ISS between patients undergoing early versus late tracheostomy in our cohort. Further studies in severely injured children are needed to compare early tracheostomy to prolonged translaryngeal intubation.
Acknowledgments This was presented at the Southwestern Surgical Congress 2013 Annual Meeting, in Santa Barbara, CA, March 24–27, 2013.
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