J Trauma Acute Care Surg. 2021 Sep 09; doi: 10.1097/TA.0000000000003394. Epub 2021 Sep 09.
Timing of tracheostomy in acute traumatic spinal cord injury: a systematic review and meta-analysis.
The journal of trauma and acute care surgery
Sarah J Foran, Shaurya Taran, J M Singh, Demetrios James Kutsogiannis, Victoria McCredie
Affiliations
Affiliations
- University of Toronto, Temerty Faculty of Medicine, Toronto, ON Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON Canada Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON Canada Krembil Research Institute, University Health Network, Toronto, ON Canada.
PMID: 34508010
DOI: 10.1097/TA.0000000000003394
Abstract
BACKGROUND: Patients 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.
METHODS: Six 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 was obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale (NOS).
RESULTS: Seventeen 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 to 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 (ICU) 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 (VAP) and tracheostomy-related complications (RR 0.86; 95% CI 0.75 to 0.98; p = 0.02; n = 2,043 and RR 0.64; 95% CI 0.48 to 0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the NOS.
CONCLUSIONS: Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical ventilation, length of ICU 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 EVIDENCE: Systematic Review, Level III.PROSPERO Registration Number: CRD42020162488.
Copyright © 2021 Lippincott Williams & Wilkins, Inc.
Conflict of interest statement
Conflicts of Interest and Source of Funding: None declared.
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