Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from a rural set-up of a developing country.

BACKGROUND: Neurosurgical patients including patients with severe head injury are at risk of developing respiratory complications. These can adversely affect the outcome and can result in poor survival. Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head, facial and multisystem organ trauma. AIMS: To know the indications for performing early tracheostomy and its outcome. SETTINGS AND
DESIGN: Retrospective data analysis.
MATERIALS AND METHODS: The present study is a retrospective analysis of all patients who were admitted with the diagnosis of head injury between January 2007 and December 2009 and underwent tracheostomy at a rural tertiary care trauma center of Central India.
RESULTS: During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14-75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. Tracheostomy was performed in 30 patients with severe head injury, 9 patients with moderate head injury and in only one case of mild head injury as the patient had multiple facial injuries compromising the airway.
CONCLUSIONS: Neurocritical care is a relatively new field in India, and the facilities for critical neurosurgical patients are available only in a very few tertiary care centers mainly serving the urban areas. In the present study, we discuss our limited experience with tracheostomy in patients with head injury while facing the challenge of limited resources.

INTRODUCTION

Majority of the patients with severe head injury are at risk of developing respiratory complications that may adversely affect the outcome including survival.[12] Tracheostomy has become a routine clinical intervention in the critical care and is performed in 10–24% of ventilated adult patients.[34] Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head injuries, facial injuries and multisystem organ trauma.[25-7] Tracheostomy in this group of patients is associated with fewer risks than prolonged endotracheal intubation,[28] decreases total days of mechanical ventilation, resulting in a shorter intensive care unit (ICU) stay,[2] and apart from prevention of pneumonia and aspiration, and improving the survival in patients with difficult weaning, early tracheostomy facilitates weaning from ventilator.[1]

MATERIALS AND METHODS

The present study is a retrospective analysis of all patients who were admitted with head injury between January 2007 and December 2009 and underwent classic tracheostomy at a rural tertiary care trauma center in Central India. After getting the ethical approval, the variables analyzed were age, sex, cause of injury, Glasgow Coma Scale (GCS) score on presentation, computerized tomography (CT) scan findings, timing of tracheostomy, complications, presence of pneumonia and outcome at discharge and follow-up.

RESULTS

A total of 1926 subjects with traumatic brain injury (TBI) were admitted for neurosurgical care and 58% patients sustained a mild (GCS 13–15) head injury, 21.5% had moderate (GCS 8–12) and 15.0% had severe (GCS 3–8) TBI. During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14–75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. All the patients were resuscitated and evaluated as per advanced trauma life support (ATLS) protocol before further investigations. All the patients had injury severity score (ISS) of more than 25.

We received 7 patients already intubated in the casualty, 20 patients were intubated in the casualty, 8 patients were shifted to ICU and intubated, and direct tracheostomy was considered in 5 cases. Twenty patients had signs of diffuse brain injury on CT scan [Table 1]. All the tracheostomies were performed within 1 week of admission (mean 2.9 days) [Figure 1]. Tracheostomy was performed in 30 patients with severe head injury, in 9 patients with moderate head injury and only in one case of mild head injury as the patient had multiple facial injuries compromising the airway.

Table 1

CT scan findings

Figure 1

Timing of tracheostomy

There was evidence of rib fracture in three cases; however, there was no hemopneumothorax. Post-tracheostomy X-ray chest were normal in all the cases. 22 patients survived and 18 patients died (because of the severity of the underlying brain damage). Two patients developed tracheal stenosis at follow-up and both were managed conservatively [Table 2].

Table 2

Outcome

DISCUSSION

Tracheostomy is a routinely performed procedure in critical care set-up and plays a well-defined role in the management of critically ill patients who are expected to require prolonged mechanical ventilation.[49-15] It has been well recognized that early tracheostomy improves patient comfort, reduces work of breathing, facilitates nursing care, facilitates bronchopulmonary toileting, reduces the incidence of pneumonia, improves airway security, reduces hospital stay, lowers hospital costs, facilitates airway suctioning, and most importantly, facilitates patient weaning from ventilator (reducing the days on mechanical ventilation, decreasing the length of stay in the ICU and lowering the cost of care).[10-1216-22] Apart from these benefits, tracheostomy tube bypasses the mouth and pharynx, making it far less irritating. Further, larger diameter tubes are easier to pass through, reducing retention of secretions and are more secure than endotracheal tubes and are easier to replace if inadvertently dislodged,[23] allowing earlier mobilization of patients.[8]

In the literature, it has been opined that using admission data to support a decision several days later is flawed and will diminish the benefits of early tracheostomy, and despite evidence to support the utility of early tracheostomy, few recommendations exist to facilitate identifica-tion of appropriate patients.[24] Guided by the available evidence, we performed tracheostomy in anticipation in head injury patients. Although the decision to perform a tracheostomy was complex,[5] calculating objective scores such as GCS helped in identifying those patients who would ultimately require a tracheostomy.[25] Although it is a general consensus that translaryngeal intubation should be used routinely in trauma patients for the first 10 days and tracheostomy should be performed for those intubated for 21 days or longer,[810] we used the evidence provided in a study that TBI patients presenting with a GCS ≤8, an ISS ≥25, and ventilator days >7 are more likely to require tracheostomy, and by identifying the at-risk population, early tracheostomy would decrease the morbidity and length of stay.[26] Further, it has been recommended that patients with ≥90% risk based on ISS, age, pulmonary and neurologic factors undergo tracheostomy within 72 hours of admission, and that strong consideration for early tracheostomy be given to the patients in the ≥80% risk group.[8] According to another study, patients were eligible for tracheostomy if they were older than 15 years and had either a GCS >4 with a negative brain CT (no anatomic head injury) or a GCS >9 with a positive head CT (known anatomic head injury).[15] Apart from these, we used the concept of early tracheostomy in patients with severe head injury to provide the mechan-ical ventilatory support in the first week for airway protection and to assist in early termina-tion of mechanical ventilatory support and to shorten the ICU stay for these patients with impaired consciousness in the following days.[724252728] There has been substantial debate regarding the timing of tracheostomy[2] and has been evaluated several times in recent years with mixed results;[122129-31] but still, the timing remains controversial.

In the present study, we did not have patients younger than 14 years. Although tracheostomy has been shown to be a safe pro-cedure with an acceptable rate of complications in comatose children with brain injury,[32] there is no literature describing the use of tracheostomy to improve comfort and ease of weaning in children in whom prolonged ventilation is anticipated.[14] As described in the literature, there were no deaths attributable to tracheostomy,[20] and the major cause of the mortality was the underlying severe head injury. Although tracheostomy is an increasingly used procedure, it may be associated with complications including stomal infection, stomal hemorrhage, major vascular injury, pneumothorax, subglotic stenosis, and tracheo-esophageal fistulae;[102033] therefore, a decision to perform the procedure should not be taken lightly.[27]

In developing countries where the intensive care facilities are scarce and may not be easily available even at tertiary referral centers, many critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them.[24] In such circumstances, early tracheostomy has been shown to be beneficial in normalizing systemic physiological parameters in patients with severe head injury.[24]

CONCLUSION

Neurocritical care is a relatively new field in India and the facilities for critical neurosurgical patients are available only in very few tertiary care centers mainly serving the in urban areas facing the challenge of limited resources.[24] Although we highlighted the importance of early tracheostomy in the management of severe head injury patients in the rural set-up,[6] the paucity of data, incomplete understanding of the problem and nonavailability of definitive guidelines should be taken as challenges for further scientifically rigorous studies to answer many important clinical questions and questions related to our limitations. While performing planned prospective studies to provide evidence on the indications, tim-ing, and cost-effectiveness of the tracheostomy tech-nique in TBI patients, we need to consider the social milieu of the study population.