The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy.
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ABSTRACT:
SUBMITTER: Huang HW
PROVIDER: S-EPMC7314615 | biostudies-literature | 2020 Jun
REPOSITORIES: biostudies-literature
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The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy.
Huang Hua-Wei HW Zhang Guo-Bin GB Xu Ming M Chen Guang-Qiang GQ Zhang Xiao-Kang XK Zhang Jun-Ting JT Wu Zhen Z Zhou Jian-Xin JX
Neurosurgical review 20200625 3
We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on po ...[more]
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Project description:BackgroundAwake prone positioning (APP) is widely used in the management of patients with coronavirus disease (COVID-19). The primary objective of this study was to compare the outcome of COVID-19 patients who received early versus late APP.MethodsPost hoc analysis of data collected for a randomized controlled trial (ClinicalTrials.gov NCT04325906). Adult patients with acute hypoxemic respiratory failure secondary to COVID-19 who received APP for at least one hour were included. Early prone positioning was defined as APP initiated within 24 h of high-flow nasal cannula (HFNC) start. Primary outcomes were 28-day mortality and intubation rate.ResultsWe included 125 patients (79 male) with a mean age of 62 years. Of them, 92 (73.6%) received early APP and 33 (26.4%) received late APP. Median time from HFNC initiation to APP was 2.25 (0.8-12.82) vs 36.35 (30.2-75.23) hours in the early and late APP group (p < 0.0001), respectively. Average APP duration was 5.07 (2.0-9.05) and 3.0 (1.09-5.64) hours per day in early and late APP group (p < 0.0001), respectively. The early APP group had lower mortality compared to the late APP group (26% vs 45%, p = 0.039), but no difference was found in intubation rate. Advanced age (OR 1.12 [95% CI 1.0-1.95], p = 0.001), intubation (OR 10.65 [95% CI 2.77-40.91], p = 0.001), longer time to initiate APP (OR 1.02 [95% CI 1.0-1.04], p = 0.047) and hydrocortisone use (OR 6.2 [95% CI 1.23-31.1], p = 0.027) were associated with increased mortality.ConclusionsEarly initiation (< 24 h of HFNC use) of APP in acute hypoxemic respiratory failure secondary to COVID-19 improves 28-day survival. Trial registration ClinicalTrials.gov NCT04325906.
| S-EPMC8446738 | biostudies-literature
Project description:Stereotactic biopsy of posterior fossa lesions is often regarded as hazardous due to the critical structures in that area. Therefore, the aim of the study was to evaluate the diagnostic accuracy and safety of infratentorial stereotactic biopsy of brainstem or cerebellar lesions and its associations with other clinical, laboratory, and radiological parameters. From January 2000 to May 2021, 190 infratentorial stereotactic biopsies of posterior fossa tumors, including 108 biopsies of brainstem lesions, were performed. Moreover, 63 supratentorial biopsies of cerebral peduncle lesions were analyzed to compare the safety and efficacy of both approaches. Additionally, the presence of antibodies against Toxoplasma gondii and Epstein-Barr Virus (EBV) were documented in 67 and 66 patients, respectively, and magnetic resonance imaging (MRI) scans were evaluated in 114 patients. Only 4% of patients had minor complications and 1.5% had major complications, including one patient who died from intracranial bleeding. Nine (4.7%) biopsies were non-diagnostic. Isocitrate dehydrogenase 1 (IDH1) mutation, 1p/19q codeletion, and O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status were assessed in 29 patients, and were non-diagnostic in only 3 (10.3%) cases. Patients with high-grade gliomas (HGG) were more frequently seropositive for T. gondii than individuals with low-grade gliomas (LGG; p < 0.001). A total of 27% of HGG and 41% of LGG were non-enhancing on MRI. The infratentorial approach is generally safe and reliable for biopsy of brainstem and cerebellar lesions. In our study, the safety and efficacy of supratentorial biopsy of the cerebral peduncle and infratentorial biopsy of lesions below the cerebral peduncle were comparably high. Moreover, patients with HGG were more frequently seropositive for T. gondii than patients with LGG, and the relationship between toxoplasmosis and gliomagenesis requires further investigation.
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Project description:BACKGROUND:We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients. METHODS:This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications. RESULTS:A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P?=?0.002). The total duration of SAE (19.8?±?23.0?min vs. 3.4?±?5.3?min, P?<?0.001) and procedural time (42.2?±?21.8?min vs. 17.7?±?9.2?min, P?<?0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64?min (?: -8.64, 95% CI: -?15.070 - -2.205, P?=?0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38?min (?: 6.38, 95% CI: 0.166-0.470, P?<?0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P?=?0.047). CONCLUSIONS:This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.
| S-EPMC7267757 | biostudies-literature
Project description:ObjectiveThe aim of this study was to assess the outcomes of tracheostomy in patients with COVID-19 respiratory failure.Summary background dataTracheostomy has an essential role in managing COVID-19 patients with respiratory failure who require prolonged mechanical ventilation. However, limited data are available on how tracheostomy affects COVID-19 outcomes, and uncertainty surrounding risk of infectious transmission has led to divergent recommendations and practices.MethodsIt is a multicenter, retrospective study; data were collected on all tracheostomies performed in COVID-19 patients at 7 hospitals in 5 tertiary academic medical systems from February 1, 2020 to September 4, 2020.ResultTracheotomy was performed in 118 patients with median time from intubation to tracheostomy of 22 days (Q1-Q3: 18-25). All tracheostomies were performed employing measures to minimize aerosol generation, 78.0% by percutaneous technique, and 95.8% at bedside in negative pressure rooms. Seventy-eight (66.1%) patients were weaned from the ventilator and 18 (15.3%) patients died from causes unrelated to tracheostomy. No major procedural complications occurred. Early tracheostomy (≤14 days) was associated with decreased ventilator days; median ventilator days (Q1-Q3) among patients weaned from the ventilator in the early, middle and late groups were 21 (21-31), 34 (26.5-42), and 37 (32-41) days, respectively with P = 0.030. Compared to surgical tracheostomy, percutaneous technique was associated with faster weaning for patients weaned off the ventilator [median (Q1-Q3): 34 (29-39) vs 39 (34-51) days, P = 0.038]; decreased ventilator-associated pneumonia (58.7% vs 80.8%, P = 0.039); and among patients who were discharged, shorter intensive care unit duration [median (Q1-Q3): 33 (27-42) vs 47 (33-64) days, P = 0.009]; and shorter hospital length of stay [median (Q1-Q3): 46 (33-59) vs 59.5 (48-80) days, P = 0.001].ConclusionEarly, percutaneous tracheostomy was associated with improved outcomes compared to surgical tracheostomy in a multi-institutional series of ventilated patients with COVID-19.
| S-EPMC8265239 | biostudies-literature
Project description:Background: Spinocerebellar ataxia type 3 (SCA) is a cerebellum-dominant degenerative disorder that is characterized primarily by infratentorial damage, although less severe supratentorial involvement may contribute to the clinical manifestation. These impairments may result from the efferent loss of the cerebellar cortex and degeneration of the cerebral cortex. Method: We used the three-dimensional fractal dimension (3D-FD) method to quantify the morphological changes in the supratentorial regions and assessed atrophy in the relatively focal regions in patients with SCA3. A total of 48 patients with SCA3 and 50 sex- and age-matched healthy individuals, as the control group, participated in this study. The 3D-FD method was proposed to distinguish 97 automatic anatomical label regions of gray matter (left cerebrum: 45, right cerebrum: 45, cerebellum: 7) between healthy individuals and patients with SCA3. Results: Patients with SCA3 exhibited reduced brain complexity within both the traditional olivopontocerebellar atrophy (OPCA) pattern and specific supratentorial regions. The study results confirmed the extensive involvement of extracerebellar regions in SCA3. The atrophied regions of SCA3 in infratentorial and supratentorial cortex showed a wide range of overlapped areas as in two functional cortexes, namely cerebellum-related cortex and basal ganglia-related cortex. Conclusions: Our results found that the atrophy of the SCA3 are not only limited in the infratentorial regions. Both cerebellar related cortex and basal ganglia related cortex were affected in the disease process of SCA3. Our findings might correlate to the common symptoms of SCA3, such as ataxia, Parkinsonism, dysarthria, and dysmetria. SCA3 should no longer be considered a disease limited to the cerebellum and its connections; rather, it should be considered a pathology affecting the whole brain.
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Project description:ObjectivesTo evaluate the optimal timing of tracheostomy for injured adolescents.DesignRetrospective cohort study.SettingTrauma facilities in the United States.PatientsAdolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge.InterventionsNone.Measurements and main resultsAfter stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point.ConclusionsFor injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.
| S-EPMC8259766 | biostudies-literature
Project description:Risk factors for major adverse events late after Fontan palliation are unknown. Prior studies have suggested ventricular function and morphology as important risk factors. The aim of this study is to (1) characterize the late major adverse event profile in adult Fontan patients and (2) identify additional risk factors that may contribute to adverse outcomes.A retrospective review of all adult patients >15 years post-Fontan seen at a tertiary academic center was conducted. Clinical, laboratory, cardiac data, and abdominal imaging were collected via chart review. Major adverse events (death, cardiac transplantation, or listing) were identified, and timing of events was plotted using Kaplan-Meier methods. Univariate and multivariate logistic regression was used to determine independent predictors of late-term events.A total of 123 adult Fontan patients were identified (mean time post-Fontan 22.4 years [±4.4]). Major adverse events occurred in 19/123 patients (15%). In this 15-year survivor cohort, transplant-free survival rates were 94.6%, 82.9%, and 59.8% at 20, 25, and 30 years postoperation, respectively. Modes of death were Fontan failure with preserved function (4), congestive heart failure with decreased function (2), sudden death (2), thromboembolic event (1), post-Fontan conversion (2), and posttransplant (2). No differences in adverse outcomes were found based on morphology of the systemic ventricle, Fontan type, or systolic ventricular function. On the other hand, features of portal hypertension (OR 19.0, CI 4.7-77.3, P?<?.0001), presence of a pacemaker (OR 13.4, CI 2.6-69.8, P?=?.002), and systemic oxygen desaturation (OR 0.86, CI 0.75-0.98, P?=?.02) were risk factors for major adverse events in the multivariate analysis.In adult Fontan patients surviving >15 years post-Fontan, portal hypertension, oxygen desaturation, and need for pacemaker were predictive of adverse events. Traditional measures may not predict late-term outcomes in adult survivors; further study of the liver's role in late outcomes is warranted.
| S-EPMC4512755 | biostudies-literature
Project description:ObjectiveMost studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated.MethodsWe used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly.ResultsA total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]).ConclusionsWith 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.
| S-EPMC3669222 | biostudies-literature
Project description:ObjectiveThe objective of the study was to determine whether early infratentorial and/or spinal cord lesions are long-term cumulative predictors of disability progression in multiple sclerosis (MS).MethodsWe selected 153 MS patients from the longitudinal Amsterdam MS cohort. Lesion analysis was performed at baseline and year 2. Disability progression after 6 and 11 years was measured using the Expanded Disability Status Scale (EDSS) and EDSS-plus (including 25-foot walk and 9-hole peg test). Patients with spinal cord or infratentorial lesions were compared for the risk of 6- and 11-year disability progression to patients without spinal cord or infratentorial lesions, respectively. Subsequently, patients with lesions on both locations were compared to patients with only spinal cord or only infratentorial lesions.ResultsBaseline spinal cord lesions show a higher risk of 6-year EDSS progression (odds ratio (OR): 3.6, p = 0.007) and EDSS-plus progression (OR: 2.5, p = 0.028) and 11-year EDSS progression (OR: 2.8, p = 0.047). Patients with both infratentorial and spinal cord lesions did not have a higher risk of 6-year disability progression than patients with only infratentorial or only spinal cord lesions.ConclusionThe presence of early spinal cord lesions seems to be a dominant risk factor of disability progression. Simultaneous presence of early infratentorial and spinal cord lesions did not undisputedly predict disability progression.
| S-EPMC7543019 | biostudies-literature
Project description:The timing of immune-related adverse events (irAE) associated with immune checkpoint inhibitors (ICI) is highly variable. Although the development of irAE has been associated with ICI clinical benefit, how irAE timing influences this association is unknown. We analyzed two independent cohorts including 154 patients with non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors at a single institution (UTSW cohort) and a multi-center cohort of 433 patients with NSCLC who received second-line anti-PD-1/PD-L1 therapy (Global cohort) to assess the association between ICI outcomes and irAE timing. In both cohorts, late-onset irAE occurring more than 3 months after ICI initiation compared to irAE occurring earlier were associated with greater rates of radiographic response (UTSW cohort, 41% versus 28%, P = .26; Global cohort, 60% versus 35%, P = .02), longer progression-free (UTSW cohort, 13.7 versus 5.6 months, P < .01; Global cohort, not reached versus 6.0 months, P < .01) and overall survival (UTSW cohort, 30.9 versus 14.6 months, P < .01; Global cohort, not reached versus 10.6 months, P < .01). Modified landmark analysis at 6 months confirmed an overall survival difference between early- and late-onset irAE. Late-onset irAE was similarly associated with greater response rates and prolonged survival in a cohort of 130 patients with non-NSCLC malignancies, suggesting a conserved association across tumor types. The favorable association between irAE and ICI clinical outcomes may be attributed to later-onset events, which is not wholly explained by survivor bias. These results allude to a distinct biology between early- and late-onset irAE and may guide clinician expectations and thresholds for continuing or modifying immunotherapy.
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