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Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis.

ABSTRACT: Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle-Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.

SUBMITTER: Marra A

PROVIDER: S-EPMC8348593 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundPatients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes.MethodsSix databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale.ResultsSeventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale.ConclusionEarly tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes.Level of evidenceSystematic Review, level III.

Project description:ObjectiveTo synthesize reported long-term outcomes in patients undergoing tracheostomy after severe acute brain injury (SABI).MethodsWe systematically searched PubMed, EMBASE, and Cochrane Library for studies in English, German, and Spanish between 1990 and 2019, reporting outcomes in patients with SABI who underwent tracheostomy. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the meta-analyses of observational studies in epidemiology guidelines. We excluded studies reporting on less than 10 patients, mixed populations with other neurological diseases, or studies assessing highly select subgroups defined by age or procedures. Data were extracted independently by two investigators. Results were pooled using random effects modeling. The primary outcome was long-term functional outcome (mRS or GOS) at 6-12 months. Secondary outcomes included hospital and long-term mortality, decannulation rates, and discharge home rates.ResultsOf 1405 studies identified, 61 underwent full manuscript review and 19 studies comprising 35,362 patients from 10 countries were included in the meta-analysis. The primary outcome was available from five studies with 451 patients. At 6-12 months, about one-third of patients (30%; 95% confidence interval [CI] 17-48) achieved independence, and about one-third survived in a dependent state (36%, 95% CI 28-46%). The pooled short-term mortality for 19,048 patients was 12%, (95% CI 9-17%) with no significant difference between stroke (10%) and TBI patients (13%), and the pooled long-term mortality was 21% (95% CI 11-36). Decannulation occurred in 79% (95% CI 51-93%) of survivors. Heterogeneity was high for most outcome assessments (I2 > 75%).ConclusionsOur findings suggest that about one in three patients with SABI who undergo tracheostomy may eventually achieve independence. Future research is needed to understand the reasons for the heterogeneity between studies and to identify those patients with promising outcomes as well as factors influencing outcome.

Project description:IntroductionPost-traumatic epilepsy (PTE) is a recognised complication of traumatic brain injury (TBI), and is associated with higher rates of mortality and morbidity when compared with patients with TBI who do not develop PTE. The majority of the literature on PTE has focused on adult populations, and consequently there is a paucity of information regarding paediatric cohorts. Additionally, there is considerable heterogeneity surrounding the reported incidence of PTE following childhood TBI in the current literature. The primary aim of our study is to summarise reported PTE incidences in paediatric populations to derive an accurate estimate of the global incidence of PTE following childhood TBI. Our secondary aim is to explore risk factors that increase the likelihood of developing PTE.Methods and analysisA systematic literature search of Embase (1947-2021), PubMed (1996-2021) and Web of Science (1900-2021) will be conducted. Publications in English that report the incidence of PTE in populations under 18 years of age will be included. Publications that evaluate fewer than 10 patients, report an alternative cause of epilepsy, or in which a paediatric cohort is not discernable, will be excluded. Independent investigators will identify the relevant publications, and discrepancies will be adjudicated by a third independent investigator. Data extracted will include incidence of PTE, time intervals between TBI and PTE, seizure characteristics, injury characteristics, patient demographics and clinical data. Data extraction will be performed by two independent investigators and cross-checked by a third investigator. A descriptive analysis of PTE incidence will be conducted and a weighted mean will be calculated. If sufficient data are available, stratified meta-analysis of subgroups will also be conducted.Ethics and disseminationEthics approval was not required for this study. We intend to publish our findings in a high-quality peer-reviewed journal on completion.Prospero registration numberCRD42021245802.

Project description:OBJECTIVES:Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock. DESIGN:Systematic review. DATA SOURCES:We searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES:Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury. RESULTS:Of 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function. CONCLUSIONS:Existing data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation. TRIAL REGISTRATION NUMBER:CRD42016033437.

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Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis.

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