K. Carlson1, N. K. Dhillon1, P. Ng1, N. T. Linaval1, G. M. Thomsen1, D. R. Margulies1, E. J. Ley1, G. Barmparas1 1Cedars-Sinai Medical Center,Los Angeles, CA, USA
Introduction: Performance of percutaneous tracheostomy (PT) in intensive care unit (ICU) trauma patients with prolonged ventilatory support is associated with decreased ventilation days. Nonetheless, clinicians might hesitate to perform this procedure on elderly patients due to presumed higher overall mortality risk and to avoid unnecessary interventions. The purpose of this study was to investigate whether elderly patients are less likely to undergo PT and whether this has an impact on mortality.
Methods: Patients 18 years or older with at least 48 hours on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Transferred patients and patients who underwent PT placement within 48 hours or after 30 days from admission were excluded. Patients were divided based on age: ≤80 years (YOUNG) and > 80 years old (OLD) and were compared using standard statistical tools. The primary outcome was mortality. To account for the timing of mortality, a Cox regression model with a time dependent variable was utilized to calculate the adjusted hazard ratio (AHR) for mortality between those receiving a PT placement and those who did not.
Results: Over the 9-year study period 214,045 patients met inclusion criteria. Of those, 13,954 (6.5%) were older than 80 years. OLD patients were significantly less likely to undergo a PT (16.1% vs. 23.8%, p<0.01). Among those undergoing a PT, OLD had a longer duration of ventilatory support prior to the procedure (median: 10 vs. 9 days, p<0.01), however, there was no significant difference in the post-PT ventilation days (median: 7 vs. 7 days, p=0.82). The overall mortality was significantly higher in OLD patients (41.8% vs. 15.6%, p<0.01). In the YOUNG cohort, those undergoing a PT had a significantly lower overall mortality (6.6% vs. 18.4%, p<0.01) compared to those with no PT. Similarly, in the OLD cohort, PT was associated with significantly lower mortality (16.3% vs. 46.7%, p<0.01). In a Cox regression model adjusting for gender, injury severity score (ISS), admission Glasgow Coma Scale (GCS) score, and admission systolic blood pressure, the AHR for mortality for younger patients receiving tracheostomy was 0.43 (adjusted p<0.01) compared to those not receiving a tracheostomy. The AHR for elderly patients was lower, at 0.38 (adjusted p<0.01).
Conclusion: In ventilated trauma patients, percutaneous tracheostomy is associated with a higher overall survival and this survival benefit is more profound in elderly patients. Delaying or even avoiding this procedure in elderly patients might not be justified.