S. Ali1, T. Coaston1, K. Ali1, G. Porter1, E. Aguayo1, A. Tillou1,2,3, G. Barmparas4, P. Benharash1,2 1David Geffen School Of Medicine, University Of California At Los Angeles, Surgery, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Center For Advanced Surgical & Interventional Technology, Los Angeles, CA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Trauma, Los Angeles, CA, USA 4Cedars-Sinai Medical Center, Division Of Trauma, Emergency Surgery And Surgical Critical Care, Los Angeles, CA, USA
Introduction: The optimal timing for tracheostomy among patients with traumatic brain injury (TBI) remains controversial. Earlier tracheostomy is hypothesized to reduce sedation requirements and allow for earlier mobility while delaying the procedure may avoid incident complications. We examined the association of tracheostomy timing with clinical endpoints among a national cohort of TBI patients.
Methods: All adult patients (≥18 years) with TBI, defined as head abbreviated injury scale ≥3, undergoing tracheostomy were identified in the 2018 to 2021 Trauma Quality Improvement Program (TQIP) database. Patients were stratified into groups labeled Early (≤10 days) and Delayed (>10 days) using the median day of tracheostomy initiation of the study cohort. Comparison of patient demographics including age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) between Early and Delayed were performed. Multivariable regression models were developed to assess the association between tracheostomy timing and outcomes including in-hospital mortality, pneumonia, and total ventilator days.
Results: Of 24,517 patients, 51.1% underwent tracheostomy within 10 days of admission and were categorized as Early. Compared to Delayed, Early were more commonly younger (42 [28-59] vs 48 years [31-63]; p<0.001) and privately insured (42.9 vs 41.1%, p<0.001). Additionally, Early had a lower median GCS (5 [3-10] vs 6 [3-12], p<0.001) as well as rates of neurosurgical intervention (48.3 vs 54.0%, p<0.001) compared to Delayed. However, ISS (27 [22-35] vs 29 [22-35], p=0.13) was similar between groups. Following multivariable adjustment, factors associated with increased likelihood of early tracheostomy included penetrating trauma (Adjusted Odds Ratio [AOR] 1.53, 95% Confidence Interval [CI] 1.37-1.72; ref: Blunt), severe facial injury (AOR 1.55, 95% CI 1.39-1.72), and increasing hospital annual volume (AOR 1.07 per 10 cases, 95% CI 1.05-1.08; Figure 1A). While early tracheostomy did not alter odds of mortality (AOR 1.10, 95% CI 0.99-1.24), patients had reduced pneumonia (AOR 0.66, 95% CI 0.62-0.21), deep vein thrombosis (AOR 0.63, 95% CI 0.58-0.69), and decubitus ulcer (AOR 0.50, 95% CI 0.46-0.55), with delayed as reference. Early tracheostomy was also associated with reduced ventilator days (β -7.05 days, 95% CI -7.35- -6.75; Figure 1B).
Conclusion: After risk adjustment, early tracheostomy appears to be associated with reduced likelihood of complications without altering the odds of mortality. These findings suggest the safety of early tracheostomy and potential improvements in several endpoints. Further prospective studies are warranted to explore the underlying mechanisms of this association.