Lucy Z Kornblith1, Matthew E Kutcher, Rachael A Callcut, Brittney J Redick, Charles K Hu, Thomas H Cogbill, Christopher C Baker, Mark L Shapiro, Clay C Burlew, Krista L Kaups, Marc A DeMoya, James M Haan, Christopher H Koontz, Samuel J Zolin, Stephanie D Gordy, David V Shatz, Doug B Paul, Mitchell J Cohen. 1. From the Department of Surgery (L.Z.K., M.E.K., R.A.C., B.J.R., M.J.C.), University of California San Francisco, San Francisco General Hospital, San Francisco; and Department of Surgery (K.L.K.), Community Regional Medical Center/University of California San Francisco, Fresno, California; Trauma Services (C.K.H.), Scottsdale Healthcare Osborn Medical Center, Scottsdale, Arizona; Department of Surgery (T.H.C.), Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin; Department of Surgery (C.C.Ba.), Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Division of Trauma, Surgical Critical Care, and Acute Care Surgery (M.L.S.), Duke University Medical Center, Durham, North Carolina; Department of Surgery (C.C.Bu.), Denver Health Medical Center, University of Colorado, Denver, Colorado; Division of Trauma, Emergency Surgery and Surgical Critical Care (M.D.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (J.M.H.), Via Christi Regional Medical Center, Wichita, Kansas; Department of Surgery (C.H.K.), New York University Langone Medical Center, New York, New York; Department of General Surgery and Trauma (S.J.Z.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (S.D.G.), Oregon Health Sciences University, Portland, Oregon; Department of Surgery (D.V.S.), University of California, Davis Medical Center, Davis, California; Department of Surgery (D.B.P.), Grant Medical Center, Columbus, Ohio.
Abstract
BACKGROUND: Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS: Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS: A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION: While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE: Prognostic study, level III.
BACKGROUND:Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS: Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. RESULTS: A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). CONCLUSION: While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE: Prognostic study, level III.
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