V. Young1, P. Evans1, H. Phelps1, M. Raees1, S. Zhao1, C. Lovvorn1, A. Greeno1, B. Brake1, C. Shannon1, H. Lovvorn1 1Vanderbilt University Medical Center,Nashville, TN, USA
Introduction:
The Brain Trauma Foundation recommends early tracheostomy in adult patients sustaining profound traumatic brain injury (TBI) and requiring prolonged mechanical ventilation (MV). This practice has been recommended for the management of pediatric patients, but its applicability and efficacy have not been reported. The purpose of this study was to evaluate practice biases and patient variables between adult and pediatric providers regarding tracheostomy in children sustaining TBI.
Methods:
The comprehensive trauma registry of a single center was queried to identify patients ≤ 18 years who presented between 2013-2017 with profound TBI and required MV. Demographic characteristics, clinical parameters, and outcomes were compared between patients treated at independent adult and pediatric hospitals and those who did or did not receive tracheostomy. Trauma care providers at both the adult and children’s hospitals were surveyed regarding their practice tendencies and inclinations regarding the role of tracheostomy in these patients.
Results:
In this cohort (n=197), 43 (21.8%) patients received tracheostomy. Demographic characteristics were not significantly different between children who did and did not receive tracheostomy. Adult (n=29, 39.7%) compared to pediatric (n=14, 11.3%) providers placed more tracheostomies (p<0.001). Tracheostomy occurred earlier in the adult than the pediatric hospital (day 6.10 ± 2.93 versus 15.14 ± 8.55, p=0.002). Injury severity score (ISS; OR 1.12, CI 95 1.06-1.18; p=0.0438), intracranial pressure (ICP) monitor duration (OR 1.11, CI 95 1.07-1.17; p=0.0162), and facial fractures (OR 2.22, CI 95 1.57-3.15; p=0.0284) were associated with tracheostomy placement. Among survivors, Kaplan-Meier analysis showed a median ventilation of 10 days with tracheostomy versus 3 days without (p<0.001). A multivariate analysis of age, gender, and ISS also found tracheostomy to correlate with longer MV, ICU duration, and hospital days (p<0.0001). Detailed survey of adult and pediatric trauma providers suggested biases for earlier and more liberal tracheostomy in TBI patients treated at the adult hospital.
Conclusion:
Attitudes and practice patterns differed between adult and pediatric providers regarding tracheostomy to support pediatric TBI patients. Potential predictors for early tracheostomy in young patients sustaining profound TBI included facial fractures, duration of ICP monitoring, and ISS. In multivariate analysis of age, gender, and ISS, tracheostomy correlated with longer duration of total MV, increased ICU days and longer hospital stays. Further work is needed to evaluate if tracheostomy is indicated earlier in these patients.
