Early vs. Late Tracheostomy in Neurotrauma Patients

1. Early vs. Late Tracheostomy in Neurotrauma Patients Meghan Blair, Lacey Penrod, Victoria Pierce, & Gabriel Speth

2. In neurotrauma patients, do early tracheotomies performed within seven days versus 28 days result in earlier weaning from the ventilator, decreased rates of pneumonia and shorter length of stay in the intensive care unit? PICO QUESTION

3. Lack of sufficient research. Practice based upon physician discretion. Discrepancy among healthcare providers regarding how timing of tracheotomy affects patient outcomes. Identification of the Problem

4. According to the CDC 235,000 people sustaining traumatic brain injury (TBI) are hospitalized annually in the U.S. The mean incremental cost of mechanical ventilation is $1,522 per day (Dasta, McLaughlin, Mody, & Piech, 2005). Extent of the Problem

5. ICU average daily cost with mechanical ventilation is $3,968 (Dasta, McLaughlin, Mody, & Piech, 2005). On average, Ventilator-Acquired Pneumonia (VAP) costs a total of $10,000 per patient (Vincent, 2007). Extent of the Problem

6. Systematic Reviews Prospective Randomized Studies Randomized Controlled Trials Retrospective Studies Meta-Analyses Review of the Literature

7. Early Tracheotomy Pros Cons Shorter stay in ICU Fewer days on mechanical ventilation No significant difference in rates of pneumonia or mortality Psychosocial issues

8. Critique of the Literature Pros Cons Peer-reviewed data Randomized-controlled trials Homogenous populations Clearly defined criteria for timing of tracheotomies Lack of consideration of external variables Nursing care Small sample size Lack of differentiation between types of trauma Mainly retrospective studies

9. Pneumonia Statistics Early Tracheotomy Late Tracheotomy Rodriguez (51) 78% Armstrong (62) 76% Kluger (55) 14% Lesnik (32) 19% Rodriquez (55) 96% Armstrong (95) 84% Kluger (65) 37% Lesnik (69) 59%

10. Ventilator Days Statistics Early Tracheotomy Late Tracheotomy Rodriguez (51) 12 ± 7.1 days Armstrong (62) 15 ± 12 days Lesnik (32) 6 ± 3 days Bouderka (31) 14.5 ± 7.3 days Rodriguez (55) 32 ± 22.2 days Armstrong (95) 29 ± 26 days Lesnik (69) 21 ± 12 days Bouderka (31) 17.5 ± 10.6 days

11. ICU Days Statistics Early Tracheotomy Late Tracheotomy D’Amelio (21) 13 ± 6 days Sugerman – brain injury (35) 16 ± 5.9 days Sugerman – nonbrain injury (13) 30 ± 18 days D’Amelio (10) 26 ± 13 days Sugerman – brain injury (13) 19 ± 11.3 days Sugerman – nonbrain injury (20) 30 ± 22 days

12. For patients with severe head trauma, tracheotomies should be implemented within seven days if the need for artificial ventilation is anticipated to exceed 21 days. Organizational protocol should be established to determine timing of tracheotomies. Recommendation

13. Monitor patient outcomes after implementation and compare with data prior to early tracheotomies. This would include analysis of: VAP rates Length of ICU stay Days on the ventilator Evaluation

14. Additional research studies should consider: Effects of external variables such as nursing care Including larger sample sizes Performing randomized controlled trials as opposed to retrospective studies Suggestions for Further Study

15. What effects does nursing care of ventilated patients have on outcomes? What other dependent variables should be considered when implementing early tracheotomy? Physiological factors Psychosocial aspects Cost New Research Questions

16. Ahmed, N., & Kuo, Y. (2007). Early versus late tracheostomy in patients with severe traumatic brain injury. Surgical Infections, 8(3), 343-347. Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27(4), 32-39. Barquist, E.S., Amortegui, J., Hallal, A., Giannotti, G., Whinney, R., Alzamel, H., & MacLeod, J. (2006). Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. The Journal of Trauma: Injury, Infection and Critical Care, 60(1), 91-97. Bouderka, M., Fakhir, B., Bouaggad, A., Hmamouchi, B., Hamoudi, D., & Harti, A. (2004). Early tracheostomy versus prolonged endotracheal intubation in severe head injury. Journal of Trauma: Injur,y Infection and Critical Care, 57(2), 251-254. References

17. Center for Disease Control and Prevention. (2009). What is Traumatic Brain Injury? Retrieved April 17, 2009, from http://www.cdc.gov/ncipc/tbi/TBI.htm. Dasta, J., McLaughlin, T., Mody, S., & Piech, C. (2005). Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Critical Care Medicine, 33(6), 1266-1271. Dunham, C., & Ransom, K. (2006). Assessment of early tracheostomy in trauma patients: a systematic review and meta-analysis. The American Surgeon, (57)3, 276-281. Gilony, D., Gilboa, D., Blumstein, T., Murad, H. Talmi, Y., Kronenberg, J. & Wolf, M. (2005). Effects of tracheostomy on well-being and body-image perceptions. American Academy of Otolaryngology-Head and Neck Surgery, 133(3), 366-371. References

18. Griffiths, J., Barber, V.S., Morgan, L., & Young, D.J. (2005). Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ, 330. doi: 10.1136/bmj.38467.485671.E0. Lindgren, V.A., & Ames, N.J. (2005). Caring for patients on mechanical ventilation. American Journal of Nursing, 105(5), 50-60. Vincent, J.L. (2007). Intensive care medicine: Annual update 2007. Berlin: Springer. References