气管切开时机对重型脑外伤的影响研究

Effects of tracheostomy timing in patients with acute severe brain injury

目的评价气管切开(气切)时机对重型脑外伤的影响。方法回顾性分析2001年5月至2010年12月采用经皮扩张气管切开术(PDT)行气切的需长时间机械通气(MV)且格拉斯哥昏迷量表(GCS)评分小于9分的重型脑外伤患者167例。依据经口插管MV时间将患者分成两组,≤7d行PDT的患者81例为早期气切组(ET),>7d行PDT的患者86例为晚期气切组(LT),比较两组患者在临床基础特征、口插管MV时间、PDT时间、PDT后MV时间、总MV时间,PDT后住ICU时间、ICU住院时间和总住院时间以及病死率,并进行相关性分析。结果两组患者在年龄、性别、急性生理慢性健康状况(APACHE)Ⅱ评分、GCS评分、损伤严重度评分和开颅手术率上,差异均无统计学意义(P均>0.05)。ET组显著缩短了口插管MV时间与PDT时间([5.16±1.33)vs.(11.64±4.25)d,P=0.000]以及PDT后MV时间(中位数:15.0vs.17.0d,P=0.028)和总MV时间(中位数:18.0vs.26.0d,P=0.037),同样缩短了PDT后住ICU时间(中位数:16.0vs.21.0d,P=0.005)和ICU住院时间(中位数:21.0vs.32.0d,P=0.000)。但两组在总住院时间(中位数:62.0vs.68.0d,P=0.497)、ICU病死率(17%vs.14%,P=0.553)和住院病死率(25%vs.28.4%,P=0.645)均无差异。相关分析总MV时间与PDT时间呈正相关(r=0.552,P<0.001),多因素分析总MV时间是ICU住院时间延长的独立危险因素(P<0.001)。结论重型脑外伤患者行早期气切可缩短MV时间和ICU住院时间,但不影响患者的预后。对重型脑外伤患者气管切开时机宜采用7d内进行。

Objective To elevate the effects of tracheostomy timing in patients with acute severe brain injury. Methods A total of 167 patients with acute severe brain injury, underwent percutaneous dilational tracheostomy （PDT） from May 2001 to December 2010 with prolonged mechanical ventilation （MV） and glassgow coma scale （GCS） score〈9, were retrospectively studied. The patients were divided into two groups： early tracheostomy （ET） group （81 cases）, received PDT within the first 7 days after endotracheal intuhation （EI） and late tracheostomy （LT） group （86 cases）, received PDT after day 7. The clinical characteristic, EI-MV days, PDT days, post-PDT MV periods, total duration of MV, post-PDT intensive care unit （ICU） stay, length of stay in the ICU and in hospital, and mortality rates were analyzed and compared between the two groups. Linear correlation or multivariate analysis was performed to test the correlation between PDT days and total duration of MV, and assess the impact of total duration of MV in ICU stay. Results No differences were found in age, sex, acute physiology and chronic health evaluation （APACHE）Ⅱ scores, GCS scores, injury severity scores and craniotomy rates between the two groups （all P〉0.05）. EI-MV days and PDT days [（5.16±1.33） vs. （11.64±4.25） days, P=0.O00], post- PDT MV periods （median： 15.0 vs. 17.0 days, P=0.028）and total duration of MV （median： 18.0 vs. 26.0 days, P=0.037） were significantly shorter than the ET group. Similarly, post-PDT ICU stay （median： 16.0 vs. 21.0 days, P=0.005） and the length of ICU stay （median： 21.0 vs. 32.0 days, P=-0.000） were significantly shorter. But the length of hospital stay （median： 62.0 vs. 68.0 days, P=0.497）, the ICU mortality rates （17% vs. 14%, P=0.553） and the hospital mortality rate （25% vs. 28.4%, P= 0.645） showed no difference between the ET group and LT group. Linear correlation analysis results showed the total duration of MV was positively correlated with the PDT days （r=0.552, P〈0.001）, and the multivariate analysis suggested that the total duration of MV was an independent predictor of prolonged ICU stay （P〈0.001）. Conclusions Tracheostomy within 7 d should be adopted in acute severe brain injury patients. It may shorten the duration of MV and length of stay in ICU, but do not result in statistically significant improvement in ICU and hospital outcome.