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Timing of Tracheostomy Placement among Children with Severe Traumatic Brain Injury

A Propensity-Matched Analysis

McLaughlin, Cory MD1; Darcy, David MD1; Park, Caron MS3,4; Lane, Christianne J PhD3,4; Mack, Wendy J PhD3,4; Bliss, David W. MD1,2; Bhalla, Anoopindar MD5,6; Upperman, Jeffrey S. MD1,2; Nathens, Avery B. MD, MPH, PhD7,8; Burd, Randall S. MD, PhD9; Jensen, Aaron R. MD, MEd10

Journal of Trauma and Acute Care Surgery: March 13, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/TA.0000000000002237
Original Article: PDF Only

Background Early tracheostomy has been associated with shorter hospital stay and fewer complications in adult trauma patients. Guidelines for tracheostomy have not been established for children with severe TBI. The purpose of this study was to 1) define nationwide trends in time to extubation and time to tracheostomy; and 2) determine if early tracheostomy is associated with decreased length of stay and fewer complications in children with severe TBI.

Methods Records of children (<15 years) with severe TBI (head abbreviated injury severity, AIS ≥3) who were mechanically ventilated (>48h) were obtained from the National Trauma Data Bank (2007-2015). Outcomes after early (≤14 days) and late (≥15 days) tracheostomy placement were compared using 1:1 propensity score matching to control for potential confounding by indication. Propensity scores were calculated based on age, race, pulse, blood pressure, GCS-motor score, injury mechanism, associated injury AIS scores, TBI subtype, craniotomy, and ICP monitor placement.

Results Among 6,101 children with severe TBI, 5,740 (94%) were extubated or died without tracheostomy, 95% of the time within 18 days. Tracheostomy was performed in 361 children (6%) at a median [IQR] of 15 [10,22] days. Using propensity score matching, we compared 121 matched pairs with early or late tracheostomy. Early tracheostomy was associated with fewer ventilator days (14 [9,19] versus 25 [19,35]), ICU days (19 [14,25] versus 31 [24,43]), and hospital days (26 [19,41] versus 39 [31,54], all p<0.05). Pneumonia (24% versus 41%), venous thromboembolism (3% versus 13%) and decubitus ulcer (4% versus 13%) occurred less frequently with early tracheostomy (p<0.05).

Conclusions Early tracheostomy is associated with shorter hospital stay and fewer complications among children with severe TBI. Extubation without tracheostomy is rare beyond 18 days after injury.

Level of Evidence III; Retrospective comparative study

Study Type Prognostic and Epidemiological

1Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA 90027

2Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033

3Southern California Clinical and Translational Science Institute (SC-CTSI), Los Angeles, CA 90033

4Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033

5Division of Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027

6Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033

7American College of Surgeons, Chicago, IL

8Department of Surgery, University of Toronto, Toronto, ON

9Division of Burn and Trauma Surgery, Children’s National Medical Center, Washington, DC

10Division of Pediatric General Surgery, UCSF Benioff Children’s Hospital Oakland, Oakland, CA

This work was presented at the 5th Annual Meeting of the Pediatric Trauma Society, November 9, 2018, Houston, TX

Author Contact Information:

Corresponding author: Aaron R Jensen, MD, MEd UCSF Benioff Children’s Hospital Oakland Division of Pediatric General Surgery 744 52nd Street, OPC 4th Floor Oakland, CA 94609

Children’s Hospital Los Angeles Institutional Review Board Approval #: CHLA-16-00207

Conflict of Interest: None of the authors have any conflicts of interest to disclose.

Funding: This work was supported by grants KL2TR001854, UL1TR001855, and UL1TR000130 from the National Center for Advancing Translational Science (NCATS) of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Contributions

Study Design: CM, DD, DWB, AB, JU, ABN, RSB, ARJ

Data Collection/Analysis: CP, CJL, WJM

Data Interpretation: CP, CJL, WJM, CM, DD, AB, ARJ

Manuscript Writing: CM, DD, ARJ

Critical Revision: CP, CJL, WJM, AB, JU, ABN, RSB

© 2019 Lippincott Williams & Wilkins, Inc.